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Tevendale HD, Garraza LG, Brooks MAM, Koumans EH, House LD, Sommerfeldt HM, Brittain A, Mueller T, Fuller TR, Romero L, Fasula A, Warner L. Effects of Community-Wide Teen Pregnancy Prevention Initiatives on Local Teen Birth Rates in the United States: A Synthetic Control Approach. Prev Sci 2024:10.1007/s11121-024-01663-0. [PMID: 38578374 DOI: 10.1007/s11121-024-01663-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/29/2024] [Indexed: 04/06/2024]
Abstract
The impact of community-wide teen pregnancy prevention initiatives (CWIs) on local U.S. birth rates among adolescents aged 15 to 19 years was examined using synthetic control methodology within a quasi-experimental design. CWIs were implemented in 10 U.S. communities from 2010 to 2015. Each initiative implemented evidence-based teen pregnancy prevention interventions at local organizations and enhanced best practices in adolescent reproductive health care at local health centers, while engaging diverse community sectors. The synthetic control method was used to estimate the impact of each CWI on overall and race- and ethnicity-specific teen births relative to rates in synthetic control communities. Additionally, we estimated the overall effect of CWIs across communities by pooling results from the 10 synthetic control case studies using the mean percentile rank. Pooled data across all 10 communities indicated an estimated average of 6.6 fewer births per 1000 teens per year overall during the initiative relative to each community's synthetic control (p = .001). By race and ethnicity, there were an estimated average of 6.4 fewer births per 1000 teens per year among Black teens (p = .03), 10.7 fewer births among Hispanic teens (p = .03), and 4.2 fewer births (p = .10) among White teens. Results from individual communities indicated an intervention effect on overall and/or race/ethnicity-specific teen birth rates in five communities. This study demonstrates the value of synthetic control methods in evaluating community-level outcomes of programmatic efforts. Findings indicate the CWIs had a positive impact on teen birth rates and have the potential to address racial and ethnic disparities in those rates.
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Affiliation(s)
- Heather D Tevendale
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, 30341, USA.
| | | | | | - Emilia H Koumans
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, 30341, USA
| | - L Duane House
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, 30341, USA
| | | | - Anna Brittain
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, 30341, USA
| | - Trisha Mueller
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, 30341, USA
| | - Taleria R Fuller
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, 30341, USA
| | - Lisa Romero
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, 30341, USA
| | - Amy Fasula
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, 30341, USA
| | - Lee Warner
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, 30341, USA
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Guetterman TC, Manojlovich M. Grand rounds in methodology: designing for integration in mixed methods research. BMJ Qual Saf 2024:bmjqs-2023-016112. [PMID: 38575310 DOI: 10.1136/bmjqs-2023-016112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 03/27/2024] [Indexed: 04/06/2024]
Abstract
Mixed methods research is a popular approach used to understand persistent and complex problems related to quality and safety, such as reasons why interventions are not implemented as intended or explaining differential outcomes. However, the quality and rigour of mixed methods research proposals and publications often miss opportunities for integration, which is the core of mixed methods. Achieving integration remains challenging, and failing to integrate reduces the benefits of a mixed methods approach. Therefore, the purpose of this article is to guide quality and safety researchers in planning and designing a mixed methods study that facilitates integration. We highlight how meaningful integration in mixed methods research can be achieved by centring integration at the following levels: research question, design, methods, results and reporting and interpretation levels. A holistic view of integration through all these levels will enable researchers to provide better answers to complex problems and thereby contribute to improvement of safety and quality of care.
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Rohweder CL, Morrison A, Mottus K, Young A, Caton L, Booth R, Reed C, Shea CM, Stover AM. Virtual quality improvement collaborative with primary care practices during COVID-19: a case study within a clinically integrated network. BMJ Open Qual 2024; 13:e002400. [PMID: 38351031 PMCID: PMC10868276 DOI: 10.1136/bmjoq-2023-002400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 01/25/2024] [Indexed: 02/16/2024] Open
Abstract
INTRODUCTION Quality improvement collaboratives (QICs) are a common approach to facilitate practice change and improve care delivery. Attention to QIC implementation processes and outcomes can inform best practices for designing and delivering collaborative content. In partnership with a clinically integrated network, we evaluated implementation outcomes for a virtual QIC with independent primary care practices delivered during COVID-19. METHODS We conducted a longitudinal case study evaluation of a virtual QIC in which practices participated in bimonthly online meetings and monthly tailored QI coaching sessions from July 2020 to June 2021. Implementation outcomes included: (1) level of engagement (meeting attendance and poll questions), (2) QI capacity (assessments completed by QI coaches), (3) use of QI tools (plan-do-check-act (PDCA) cycles started and completed) and (4) participant perceptions of acceptability (interviews and surveys). RESULTS Seven clinics from five primary care practices participated in the virtual QIC. Of the seven sites, five were community health centres, three were in rural counties and clinic size ranged from 1 to 7 physicians. For engagement, all practices had at least one member attend all online QIC meetings and most (9/11 (82%)) poll respondents reported meeting with their QI coach at least once per month. For QI capacity, practice-level scores showed improvements in foundational, intermediate and advanced QI work. For QI tools used, 26 PDCA cycles were initiated with 9 completed. Most (10/11 (91%)) survey respondents were satisfied with their virtual QIC experience. Twelve interviews revealed additional themes such as challenges in obtaining real-time data and working with multiple electronic medical record systems. DISCUSSION A virtual QIC conducted with independent primary care practices during COVID-19 resulted in high participation and satisfaction. QI capacity and use of QI tools increased over 1 year. These implementation outcomes suggest that virtual QICs may be an attractive alternative to engage independent practices in QI work.
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Affiliation(s)
- Catherine L Rohweder
- Center for Women's Health Research, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
- The North Carolina Translational and Clinical Sciences Institute (NC TraCS), The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Abigail Morrison
- Department of Health Behavior, The University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Kathleen Mottus
- The North Carolina Translational and Clinical Sciences Institute (NC TraCS), The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
- Cecil G. Sheps Center for Health Services Research, The University of North Carolina, Chapel Hill, North Carolina, USA
| | - Alexa Young
- Center for Health Promotion and Disease Prevention, The University of North Carolina, Chapel Hill, North Carolina, USA
| | - Lauren Caton
- The North Carolina Translational and Clinical Sciences Institute (NC TraCS), The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
- Department of Maternal and Child Health, The University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Ronni Booth
- UNC Health Alliance, UNC Health Care System, Chapel Hill, North Carolina, USA
| | - Christine Reed
- UNC Health Alliance, UNC Health Care System, Chapel Hill, North Carolina, USA
| | - Christopher M Shea
- The North Carolina Translational and Clinical Sciences Institute (NC TraCS), The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
- Department of Health Policy and Management, The University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Angela M Stover
- The North Carolina Translational and Clinical Sciences Institute (NC TraCS), The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
- Department of Health Policy and Management, The University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
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Walton H. Towards comprehensive fidelity evaluations: consideration of enactment measures in quality improvement interventions. BMJ Qual Saf 2024; 33:78-81. [PMID: 37714701 DOI: 10.1136/bmjqs-2023-016592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 09/17/2023]
Affiliation(s)
- Holly Walton
- Department of Applied Health Research, University College London, London, UK
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Ginsburg L, Hoben M, Berta W, Doupe M, Estabrooks CA, Norton PG, Reid C, Geerts A, Wagg A. Development and validation of the Overall Fidelity Enactment Scale for Complex Interventions (OFES-CI). BMJ Qual Saf 2024; 33:98-108. [PMID: 37648435 PMCID: PMC10850642 DOI: 10.1136/bmjqs-2023-016001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 08/05/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND In many quality improvement (QI) and other complex interventions, assessing the fidelity with which participants 'enact' intervention activities (ie, implement them as intended) is underexplored. Adapting the evaluative approach used in objective structured clinical examinations, we aimed to develop and validate a practical approach to assessing fidelity enactment-the Overall Fidelity Enactment Scale for Complex Interventions (OFES-CI). METHODS We developed the OFES-CI to evaluate enactment of the SCOPE QI intervention, which teaches nursing home teams to use plan-do-study-act (PDSA) cycles. The OFES-CI was piloted and revised early in SCOPE with good inter-rater reliability, so we proceeded with a single rater. An intraclass correlation coefficient (ICC) was used to assess inter-rater reliability. For 27 SCOPE teams, we used ICC to compare two methods for assessing fidelity enactment: (1) OFES-CI ratings provided by one of five trained experts who observed structured 6 min PDSA progress presentations made at the end of SCOPE, (2) average rating of two coders' deductive content analysis of qualitative process evaluation data collected during the final 3 months of SCOPE (our gold standard). RESULTS Using Cicchetti's classification, inter-rater reliability between two coders who derived the gold standard enactment score was 'excellent' (ICC=0.93, 95% CI=0.85 to 0.97). Inter-rater reliability between the OFES-CI and the gold standard was good (ICC=0.71, 95% CI=0.46 to 0.86), after removing one team where open-text comments were discrepant with the rating. Rater feedback suggests the OFES-CI has strong face validity and positive implementation qualities (acceptability, easy to use, low training requirements). CONCLUSIONS The OFES-CI provides a promising novel approach for assessing fidelity enactment in QI and other complex interventions. It demonstrates good reliability against our gold standard assessment approach and addresses the practicality problem in fidelity assessment by virtue of its suitable implementation qualities. Steps for adapting the OFES-CI to other complex interventions are offered.
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Affiliation(s)
- Liane Ginsburg
- School of Health Policy and Management, Faculty of Health, York University, Toronto, Ontario, Canada
| | - Matthias Hoben
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Whitney Berta
- Institute of Health Policy Management and Evaluation, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Malcolm Doupe
- Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre for Care Research, Western Norway University of Applied Sciences, Bergen, Norway
| | | | - Peter G Norton
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Colin Reid
- School of Health and Exercise Science, The University of British Columbia, Kelowna, British Columbia, Canada
| | - Ariane Geerts
- School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Ontario, Canada
| | - Adrian Wagg
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Benson T. Why it is hard to use PROMs and PREMs in routine health and care. BMJ Open Qual 2023; 12:e002516. [PMID: 38135303 DOI: 10.1136/bmjoq-2023-002516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) show the results of healthcare activities as rated by patients and others. Patients or their proxies record feedback using questionnaires. These can enhance quality for all and tailored care for individuals. This paper describes obstacles that inhibit widespread use of PROMs and PREMs and some potential solutions.Implementation is a prerequisite for any innovation to succeed. Health and care services are complex and people need to be engaged at every level. Most people are cautious about proven innovations such as PROMs and PREMs but champions and leaders can help them engage. The NASSS framework (reasons for Non-adoption, Abandonment and failure to Scale up, Spread or Sustain digital health innovations) helps indicate that implementation is complex why it may be resisted.The Plan-Do-Study-Act (PDSA) approach aids implementation and helps ensure that everyone knows who should do what, when, where, how and why. Noise is an under-appreciated problem, especially when tracking patients over time such as before and after treatment. Interoperability of PROMs and PREMs with electronic health records should use Fast Health Interoperability Resources and internationally accepted coding schemes such as SNOMED CT and LOINC.Most projects need multiple measures to meet the needs of everyone involved. Measure selection should focus on their relevance, ease of use, and response rates.If these problems are avoided or mitigated, PROMs and PREMs can help deliver better patient outcomes, patient experience, staff satisfaction and health equity.
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Affiliation(s)
- Tim Benson
- R-Outcomes Ltd, Newbury, UK
- Institute of Health Informatics, UCL, London, UK
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Woodcock T, Matthew D, Palladino R, Nakubulwa M, Winn T, Bethell H, Hiles S, Moggan S, Dowell J, Sullivan P, Bell D, Cowie MR. Effect of implementing a heart failure admission care bundle on hospital readmission and mortality rates: interrupted time series study. BMJ Qual Saf 2023; 33:55-65. [PMID: 37931935 PMCID: PMC10804004 DOI: 10.1136/bmjqs-2022-015511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 08/15/2023] [Indexed: 11/08/2023]
Abstract
This study aimed to evaluate the impact of developing and implementing a care bundle intervention to improve care for patients with acute heart failure admitted to a large London hospital. The intervention comprised three elements, targeted within 24 hours of admission: N-terminal pro-B-type natriuretic peptide (NT-proBNP) test, transthoracic Doppler two-dimensional echocardiography and specialist review by cardiology team. The SHIFT-Evidence approach to quality improvement was used. During implementation, July 2015-July 2017, 1169 patients received the intervention. An interrupted time series design was used to evaluate impact on patient outcomes, including 15 618 admissions for 8951 patients. Mixed-effects multiple Poisson and log-linear regression models were fitted for count and continuous outcomes, respectively. Effect sizes are slope change ratios pre-intervention and post-intervention. The intervention was associated with reductions in emergency readmissions between 7 and 90 days (0.98, 95% CI 0.97 to 1.00), although not readmissions between 0 and 7 days post-discharge. Improvements were seen in in-hospital mortality (0.96, 95% CI 0.95 to 0.98), and there was no change in trend for hospital length of stay. Care process changes were also evaluated. Compliance with NT-proBNP testing was already high in 2014/2015 (162 of 163, 99.4%) and decreased slightly, with increased numbers audited, to 2016/2017 (1082 of 1101, 98.2%). Over this period, rates of echocardiography (84.7-98.9%) and specialist input (51.6-90.4%) improved. Care quality and outcomes can be improved for patients with acute heart failure using a care bundle approach. A systematic approach to quality improvement, and robust evaluation design, can be beneficial in supporting successful improvement and learning.
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Affiliation(s)
- Thomas Woodcock
- School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Dionne Matthew
- Strategy, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
- Life Science, LOGEX BV, Amsterdam, Netherlands
| | - Raffaele Palladino
- School of Public Health, Faculty of Medicine, Imperial College London, London, UK
- Department of Public Health, University of Naples Federico II School of Medicine and Surgery, Naples, Italy
| | - Mable Nakubulwa
- School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Trish Winn
- Research and Development, London Northwest University Healthcare NHS Trust, London, UK
| | - Hugh Bethell
- Cardiology, London Northwest University Healthcare NHS Trust, London, UK
| | - Stephen Hiles
- Research and Development, London Northwest University Healthcare NHS Trust, London, UK
| | - Susan Moggan
- Research and Development, London Northwest University Healthcare NHS Trust, London, UK
- Cardiology, London Northwest University Healthcare NHS Trust, London, UK
| | - Jackie Dowell
- Research and Development, London Northwest University Healthcare NHS Trust, London, UK
- Business Development, PHASTAR Specialist Biometric Contract Research Organisation, London, UK
| | - Paul Sullivan
- School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Derek Bell
- School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Martin R Cowie
- Royal Brompton Hospital & School of Cardiovascular Medicine, Faculty of Lifesciences & Medicine, King's College London, London, UK
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Vas V, Gyambibi L, Eftychiou L, Al-Omari H, Glass J, Smith M, Matthew D. Identifying value in healthcare transformation initiatives: an evaluation of an approach to benefits realisation. BMJ Open Qual 2023; 12:e002349. [PMID: 37857520 PMCID: PMC10603506 DOI: 10.1136/bmjoq-2023-002349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 09/25/2023] [Indexed: 10/21/2023] Open
Abstract
Benefits realisation management (BRM) aims to facilitate the process of identifying, measuring and tracking desired benefits derived from a project. Improvement methodology frameworks often describe BRM as integral to identifying and measuring value derived from transformation initiatives within the National Health Service and beyond. Despite this, reporting of benefits realisation plans and methodological approaches to identifying and measuring benefits remains surprisingly scarce.This project aimed to pilot and evaluate the application of a purpose-designed benefits mapping template with seven newly funded transformation projects across three hospitals in the UK. The scope of the template was to identify key project benefits and metrics associated with the project initiatives. Plan-do-study-act (PDSA) cycles were used to capture the approach and utilisation of the template by project teams. These methods also enabled critical review of the template as an enabler to identifying relevant benefits and project metrics.Stakeholder engagement with the templates was variable. This was attributed to clinical pressures induced by the second wave of COVID-19 in the UK. Despite this, teams were able to produce completed templates outlining a number of wide-ranging benefits. Themes of benefits drawn from the maps include patient experience, patient outcomes, staff experience, access to care and efficiency. Qualitative feedback from teams included the reported value of a structured template to help recognise all the potential benefits associated with each project initiative. The PDSA cycles highlighted the template as an early step in BRM. Further components to this process are recommended to include consensus of the key metrics to be measured, a tool that summarises the reporting details of those metrics, and an effective means to collate reported metrics overtime.
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Affiliation(s)
- Venessa Vas
- KHP Cardiovascular & Respiratory Partnership, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Loretta Gyambibi
- KHP Cardiovascular & Respiratory Partnership, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Linda Eftychiou
- KHP Cardiovascular & Respiratory Partnership, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Hassan Al-Omari
- KHP Cardiovascular & Respiratory Partnership, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - James Glass
- KHP Cardiovascular & Respiratory Partnership, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Mark Smith
- KHP Cardiovascular & Respiratory Partnership, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Dionne Matthew
- KHP Cardiovascular & Respiratory Partnership, Guy's and St Thomas' NHS Foundation Trust, London, UK
- LOGEX, Amsterdam, The Netherlands
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Bertanha M, Mellucci Filho PL, Genka CA, de Camargo PAB, Grillo VTRDS, Sertório ND, Rodrigues LDS, Sobreira ML, Lourenção PLTDA. Quantitative analysis validation for sclerotherapy treatment of lower limb telangiectasias. J Vasc Surg Venous Lymphat Disord 2023; 11:708-715. [PMID: 37030450 DOI: 10.1016/j.jvsv.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 02/28/2023] [Accepted: 03/07/2023] [Indexed: 04/10/2023]
Abstract
BACKGROUND The evaluation of sclerotherapy efficacy for lower limb telangiectasias, which is the standard treatment for such condition, is commonly assisted by scores based on before and after pictures. This method is marked by its subjectivity, which impairs the precision of studies on the subject, making it unfeasible to evaluate and compare different interventions. We hypothesize that a quantitative method for evaluating the effectiveness of sclerotherapy for lower limb telangiectasias may present more reproducible results. Reliable measurement methods and new technologies may become part of the clinical practice in the near future. METHODS Before and after treatment photographs were analyzed using a quantitative method and compared with a validated qualitative method based on improvement scores. Reliability analysis of the methods was performed, applying the intraclass correlation coefficient (ICC) and kappa coefficient with quadratic weights (Fleiss Cohen), for analysis of inter-examiner and intra-examiner agreement in both evaluation methods. Convergent validity was evaluated by applying the Spearman test. To assess the applicability of the quantitative scale, the Mann-Whitney test was used. RESULTS A better agreement between examiners is shown for the quantitative scale, with a mean kappa of .3986 (.251-.511) for qualitative analysis and a mean kappa of .788 (.655-.918) for quantitative analysis (P < .001 for all examiners). Convergent validity was achieved by correlation coefficients of .572 to .905 (P < .001). The quantitative scale results obtained between the specialists with different degrees of experience did not show statistical difference (seniors: 0.71 [-0.48/1.00] × juniors: 0.73 [-0.34/1.00]; P = .221). CONCLUSIONS Convergent validity between both analyses has been achieved, but quantitative analysis has been shown to be more reliable and can be applied by professionals of any degree of experience. The validation of quantitative analysis is a major milestone for the development of new technology and automated, reliable, applications.
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Affiliation(s)
- Matheus Bertanha
- Department of Surgery and Orthopedics, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil.
| | | | - Caroline Araujo Genka
- Department of Surgery and Orthopedics, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
| | | | | | - Nathalia Dias Sertório
- Department of Surgery and Orthopedics, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
| | - Lenize da Silva Rodrigues
- Department of Surgery and Orthopedics, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
| | - Marcone Lima Sobreira
- Department of Surgery and Orthopedics, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
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Ragheb J, Norcott A, Benn L, Shah N, McKinney A, Min L, Vlisides PE. Barriers to delirium screening and management during hospital admission: a qualitative analysis of inpatient nursing perspectives. BMC Health Serv Res 2023; 23:712. [PMID: 37386400 DOI: 10.1186/s12913-023-09681-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 06/10/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Delirium in hospitalized patients is a major public health issue, yet delirium is often unrecognized and missed during inpatient admission. The objective of this study was to identify barriers to delirium screening, identification, and management from a nursing perspective on inpatient, acute care units. METHODS This was a pre-implementation, diagnostic evaluation study to determine current practice patterns and potential barriers to optimizing delirium care at a major university hospital. A qualitative approach was used, which included focus groups of inpatient nurses working on major medical and surgical acute care units. Focus groups were conducted until signs of thematic saturation were present, and data were analyzed via inductive thematic analysis, without predetermined theories or structures. A consensus approach was utilized for transcript coding, and final themes were generated after multiple reviews of initial themes against transcript datasets. RESULTS Focus group sessions (n = 3) were held with 18 nurses across two major inpatient units. Nurses reported several barriers to successful delirium screening and management. Specific challenges included difficulty with using delirium screening tools, an organizational culture not conducive to delirium prevention, and competing clinical priorities. Proposed solutions were also discussed, including decision-support systems with automated pager alerts and associated delirium order sets, which may help improve delirium care coordination and standardization. CONCLUSION At a major university hospital, nurses affirm the difficulty experienced with delirium screening and identification, particularly due to screening tool challenges, cultural barriers, and clinical workload. These impediments may serve as targets for a future implementation trial to improve delirium screening and management.
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Affiliation(s)
- Jacqueline Ragheb
- Department of Anesthesiology, University of Michigan Medical School, 1H247 UH, 1500 East Medical Center Drive, Ann Arbor, MI, SPC-5048, 48109-5048, USA
| | - Alexandra Norcott
- Department of Internal Medicine, Division of Geriatric & Palliative Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Lakeshia Benn
- Department of Inpatient Rehabilitation, Michigan Medicine, Ann Arbor, MI, USA
- College of Health Professions & McAuley School of Nursing, University of Detroit Mercy, Detroit, MI, USA
| | - Nirav Shah
- Department of Anesthesiology, University of Michigan Medical School, 1H247 UH, 1500 East Medical Center Drive, Ann Arbor, MI, SPC-5048, 48109-5048, USA
| | - Amy McKinney
- Department of Anesthesiology, University of Michigan Medical School, 1H247 UH, 1500 East Medical Center Drive, Ann Arbor, MI, SPC-5048, 48109-5048, USA
| | - Lillian Min
- Department of Internal Medicine, Division of Geriatric & Palliative Medicine, Michigan Medicine, Ann Arbor, MI, USA
- VA Ann Arbor Healthcare System, Department of Internal Medicine, Division of Geriatric Research, Education, and Clinical Centers (GRECC), Ann Arbor, MI, USA
| | - Phillip E Vlisides
- Department of Anesthesiology, University of Michigan Medical School, 1H247 UH, 1500 East Medical Center Drive, Ann Arbor, MI, SPC-5048, 48109-5048, USA.
- Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, MI, USA.
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Söling S, Demirer I, Köberlein-Neu J, Hower KI, Müller BS, Pfaff H, Karbach U. Complex implementation mechanisms in primary care: do physicians' beliefs about the effectiveness of innovation play a mediating role? Applying a realist inquiry and structural equation modeling approach in a formative evaluation study. BMC Prim Care 2023; 24:131. [PMID: 37369994 DOI: 10.1186/s12875-023-02081-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND The adoption of digital health technologies can improve the quality of care for polypharmacy patients, if the underlying complex implementation mechanisms are better understood. Context effects play a critical role in relation to implementation mechanisms. In primary care research, evidence on the effects of context in the adoption of digital innovation for polypharmacy management is lacking. STUDY AIM This study aims to identify contextual factors relevant to physician behavior and how they might mediate the adoption process. METHODS The physicians who participated in this formative evaluation study (n = 218) were part of the intervention group in a cluster-randomized controlled trial (AdAM). The intervention group implemented a digital innovation for clinical decision making in polypharmacy. A three-step methodological approach was used: (1) a realist inquiry approach, which involves the description of a context-mechanism-outcome configuration for the primary care setting; (2) a belief elicitation approach, which involves qualitative content analysis and the development of a quantitative latent contextualized scale; and (3) a mediation analysis using structural equation modeling (SEM) based on quantitative survey data from physicians to assess the mediating role of the contextualized scale (n = 179). RESULTS The key dimensions of a (1) context-mechanism-outcome model were mapped and refined. A (2) latent construct of the physicians' innovation beliefs related to the effectiveness of polypharmacy management practices was identified. Innovation beliefs play a (3) mediating role between the organizational readiness to implement change (p < 0.01) and the desired behavioral intent of physicians to adopt digital innovation (p < 0.01; R2 = 0.645). Our contextualized model estimated significant mediation, with a relative size of 38% for the mediation effect. Overall, the model demonstrated good fit indices (CFI = 0.985, RMSEA = 0.034). CONCLUSION Physician adoption is directly affected by the readiness of primary care organizations for the implementation of change. In addition, the mediation analysis revealed that this relationship is indirectly influenced by primary care physicians' beliefs regarding the effectiveness of digital innovation. Both individual physician beliefs and practice organizational capacity could be equally prioritized in developing implementation strategies. The methodological approach used is suitable for the evaluation of complex implementation mechanisms. It has been proven to be an advantageous approach for formative evaluation. TRIAL REGISTRATION NCT03430336 . First registration: 12/02/2018. CLINICALTRIALS gov.
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Affiliation(s)
- Sara Söling
- Institute of Medical Sociology, Health Services Research, and Rehabilitation Sciences, Faculty of Human Sciences & Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
- Center for Health Economics and Health Services Research, Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany.
| | - Ibrahim Demirer
- Institute of Medical Sociology, Health Services Research, and Rehabilitation Sciences, Faculty of Human Sciences & Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Juliane Köberlein-Neu
- Center for Health Economics and Health Services Research, Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany
| | - Kira Isabel Hower
- Institute of Medical Sociology, Health Services Research, and Rehabilitation Sciences, Faculty of Human Sciences & Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Beate Sigrid Müller
- Institute for General Medicine, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Holger Pfaff
- Institute of Medical Sociology, Health Services Research, and Rehabilitation Sciences, Faculty of Human Sciences & Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ute Karbach
- Institute of Medical Sociology, Health Services Research, and Rehabilitation Sciences, Faculty of Human Sciences & Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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12
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Carthey J. Measurement and Monitoring of Safety Framework (MMSF): learning from its implementation in Canada. BMJ Qual Saf 2023:bmjqs-2022-015680. [PMID: 37230758 DOI: 10.1136/bmjqs-2022-015680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2023] [Indexed: 05/27/2023]
Affiliation(s)
- Jane Carthey
- Human Factors and Patient Safety, Jane Carthey Consulting, Bournemouth, UK
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13
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Voith LA, Russell KN, Lee H, Atwell MS, McKinney SJ, Thomas T, Barksdale EM. Using grounded theory to develop a theory of change for a violence intervention program. Eval Program Plann 2023; 99:102303. [PMID: 37229924 DOI: 10.1016/j.evalprogplan.2023.102303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 03/30/2023] [Accepted: 04/29/2023] [Indexed: 05/27/2023]
Abstract
Hospital-based violence intervention programs (HVIP) are critical to interrupting the cycle of violence. These interventions are considered "complex" in that they have many mechanisms of change and related outcomes. Few HVIPs clearly identify the underlying mechanisms of intervention and explicitly link those with key outcomes however, limiting the field's ability to know what works best and for whom. To develop a program theory of change for these "complex interventions," a non-linear, robust methodology that is grounded in the lived experience of those delivering and receiving services is needed. To aid researchers, evaluators, students, and program developers, we describe the use of Grounded Theory as a methodology to enhance the development of complex interventions, illuminating a non-linear approach that engages key stakeholders. To illustrate application, we describe a case example of The Antifragility Initiative, a HVIP in Cleveland, Ohio. The development of the program theory of change was conducted in four phases: (1) review of existing program documents, (2) semi-structured interviews with program developers (n = 6), (3) a focus group with program stakeholders (n = 8), and (4) interviews with caregivers and youth (n = 8). Each phase informed the next and culminated in a theoretical narrative and visual model of the Antifragility Initiative. Together, the theoretical narrative and visual model identify the underlying mechanisms that can promote change by the program.
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Affiliation(s)
- Laura A Voith
- Jack, Joseph, and Morton Mandel School of Applied Social Sciences Case Western Reserve University, United States; Center on Trauma and Adversity, United States.
| | - Katie N Russell
- Jack, Joseph, and Morton Mandel School of Applied Social Sciences Case Western Reserve University, United States
| | - Hyunjune Lee
- Jack, Joseph, and Morton Mandel School of Applied Social Sciences Case Western Reserve University, United States
| | - Meghan Salas Atwell
- Jack, Joseph, and Morton Mandel School of Applied Social Sciences Case Western Reserve University, United States; Center on Urban Poverty and Community Development, United States
| | - Sherise J McKinney
- Jack, Joseph, and Morton Mandel School of Applied Social Sciences Case Western Reserve University, United States; National Initiative on Mixed-Income Communities, United States
| | - Tito Thomas
- Case Western Reserve University School of Medicine, United States
| | - Edward M Barksdale
- Rainbow Babies and Children's Hospital/University Hospitals, United States; Case Western Reserve University School of Medicine, United States
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14
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Elg M, Gremyr I. Patient involvement in quality improvement: a survey comparing naturalistic and reflective approaches. BMJ Open Qual 2023; 12:bmjoq-2022-001981. [PMID: 37192776 DOI: 10.1136/bmjoq-2022-001981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 05/05/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND This study investigates reflective and naturalistic approaches to patient involvement in quality improvement. The reflective approach, using, for example, interviews, provides insights into patient needs and demands to support an established improvement agenda. The naturalistic approach, for example, observations, is used to discover practical problems and opportunities that professionals are currently unaware of. METHODS We assessed the use of naturalistic and reflective approaches in quality improvement to see whether they differed in their impact on patient needs, financial improvements and improved patient flows. Four possible combinations were used as a starting point: restrictive (low reflective-low naturalistic), in situ (low reflective-high naturalistic), retrospective (high reflective-low naturalistic) and blended (high reflective-high naturalistic). Data were collected through an online cross-sectional survey using a web-based survey tool. The original sample was based on a list of 472 participants enrolled in courses on improvement science in three Swedish regions. The response rate was 34%. Descriptives and ANOVA (Analysis of Variance) in SPSS V.23 were used for the statistical analysis. RESULTS The sample consisted of 16 projects characterised as restrictive, 61 as retrospective and 63 as blended. No projects were characterised as in situ. There was a significant effect of patient involvement approaches on patient flows and patient needs at the p<0.05 level (patient flows, (F(2, 128)=5.198, p=0.007) and patient needs (F(2, 127)=13.228, p=0.000)). No significant effect was found for financial results. CONCLUSIONS Moving beyond restrictive patient involvement is important to meet new patient needs and improve patient flows. This can be done either by increasing the use of a reflective approach or by increasing the use of both reflective and naturalistic approaches. A blended approach with high levels of both is likely to produce better results in addressing new patient needs and improving patient flows.
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Affiliation(s)
- Mattias Elg
- Department of Management and Engineering, Linköping University, Linkoping, Östergötland, Sweden
| | - Ida Gremyr
- Technology Management and Economics, Chalmers University of Technology, Goteborg, Sweden
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15
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MacEachern L, Ginsburg LR, Hoben M, Doupe M, Wagg A, Knopp-Sihota JA, Cranley L, Song Y, Estabrooks CA, Berta W. Developing a tool to measure enactment of complex quality improvement interventions in healthcare. BMJ Open Qual 2023; 12:bmjoq-2022-002027. [PMID: 36754540 PMCID: PMC9923287 DOI: 10.1136/bmjoq-2022-002027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 01/24/2023] [Indexed: 02/10/2023] Open
Abstract
Quality improvement (QI) projects are common in healthcare settings and often involve interdisciplinary teams working together towards a common goal. Many interventions and programmes have been introduced through research to convey QI skills and knowledge to healthcare workers, however, a few studies have attempted to differentiate between what individuals 'learn' or 'know' versus their capacity to apply their learnings in complex healthcare settings. Understanding and differentiating between delivery, receipt, and enactment of QI skills and knowledge is important because while enactment alone does not guarantee desired QI outcomes, it might be reasonably assumed that 'better enactment' is likely to lead to better outcomes. This paper describes the development, application and validation of a tool to measure enactment of core QI skills and knowledge of a complex QI intervention in a healthcare setting. Based on the Institute for Healthcare Improvement's Model for Improvement, existing QI assessment tools, literature on enactment fidelity and our research protocols, 10 indicators related to core QI skills and knowledge were determined. Definitions and assessment criteria were tested and refined in five iterative cycles. Qualitative data from four QI teams in long-term care homes were used to test and validate the tool. The final measurement tool contains 10 QI indicators and a five-point scale. Inter-rater reliability ranged from good to excellent. Usability and acceptability among raters were considered high. This measurement tool assists in identifying strengths and weaknesses of a QI team and allows for targeted feedback on core QI components. The indicators developed in our tool and the approach to tool development may be useful in other health related contexts where similar data are collected.
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Affiliation(s)
- Lauren MacEachern
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Liane R Ginsburg
- Health Policy & Management, York University, Toronto, Ontario, Canada
| | - Matthias Hoben
- School of Health Policy and Management, York University, Toronto, Ontario, Canada,Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Malcolm Doupe
- Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada,Centre for Care Research, Western Norway University of Applied Sciences, Bergen, Norway
| | - Adrian Wagg
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Lisa Cranley
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Yuting Song
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada,School of Nursing, Qingdao University, Edmonton, Shandong, China
| | | | - Whitney Berta
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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16
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Eljiz K, Greenfield D, Hogden A, Agaliotis M, Taylor R, Siddiqui N. Implementing health system improvement: resources and strategies for interprofessional teams. BMJ Open Qual 2023; 12:bmjoq-2022-001896. [PMID: 36707126 PMCID: PMC9884892 DOI: 10.1136/bmjoq-2022-001896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 11/20/2022] [Indexed: 01/28/2023] Open
Abstract
Health system improvement (HSI) is focused on systematic changes to organisational processes and practices to improve the efficient delivery of safe care and quality outcomes. Guidelines that specify how interprofessional teams conduct HSI and knowledge translation are needed. We address this urgent requirement providing health professional teams with resources and strategies to investigate, analyse and implement system-level improvements. HSI encompasses similar, yet different, inter-related activities across a continuum. The continuum spans three categories of activities, such as quality improvement, health management research and translational health management research. A HSI decision making guide and checklist, comprising six-steps, is presented that can be used to select and plan projects. This resource comprises six interconnected steps including, defining the activity, project outcome, aim, use of evidence, appropriate methodology and implementation plan. Each step has been developed focusing on an objective, actions and resources. HSI activities provide a foundation for interprofessional collaboration, allowing multiple professions to create, share and disseminate knowledge for improved healthcare. When planned and executed well, HSI projects assist clinical and corporate staff to make evidence-informed decisions and directions for the benefit of the service, organisation and sector.
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Affiliation(s)
- Kathy Eljiz
- School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
| | - David Greenfield
- School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Anne Hogden
- School of Population Health, University of New South Wales, Sydney, New South Wales, Australia,Australian Institute of Health Services Management, University of Tasmania Tasmanian School of Business and Economics, Sydney, NSW, Australia
| | - Maria Agaliotis
- Australian Institute of Health Services Management, University of Tasmania Tasmanian School of Business and Economics, Sydney, NSW, Australia
| | - Robyn Taylor
- Australian Institute of Health Services Management, University of Tasmania Tasmanian School of Business and Economics, Sydney, NSW, Australia
| | - Nazlee Siddiqui
- Australian Institute of Health Services Management, University of Tasmania Tasmanian School of Business and Economics, Sydney, NSW, Australia
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17
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Pankhurst T, Lucas L, Ryan S, Ragdale C, Gyves H, Denner L, Young I, Rathbone L, Shah A, McKee D, Coleman JJ, Evison F, Atia J, Rosser D, Garrick M, Baker R, Gallier S, Ball S. Benefits of electronic charts in intensive care and during a world health pandemic: advantages of the technology age. BMJ Open Qual 2023; 12:bmjoq-2021-001704. [PMID: 36649943 PMCID: PMC9853220 DOI: 10.1136/bmjoq-2021-001704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 03/25/2022] [Indexed: 01/19/2023] Open
Abstract
AIMS AND OBJECTIVES This study sets out to describe benefits from the implementation of electronic observation charting in intensive care units (ICU). This was an extension to the existing hospital wide digital health system. We evaluated error reduction, time-savings and the costs associated with conversion from paper to digital records. The world health emergency of COVID-19 placed extraordinary strain on ICU and staff opinion was evaluated to test how well the electronic system performed. METHODS A clinically led project group working directly with programmers developed an electronic patient record for intensive care. Data error rates, time to add data and to make calculations were studied before and after the introduction of electronic charts. User feedback was sought pre and post go-live (during the COVID-19 pandemic) and financial implications were calculated by the hospital finance teams. RESULTS Error rates equating to 219 000/year were avoided by conversion to electronic charts. Time saved was the equivalent of a nursing shift each day. Recurrent cost savings per year were estimated to be £257k. Staff were overwhelmingly positive about electronic charts in ICU, even during a health pandemic and despite redeployment into intensive care where they were using the electronic charts for the first time. DISCUSSION Electronic ICU charts have been successfully introduced into our institution with benefits in terms of patient safety through error reduction and improved care through release of nursing time. Costs have been reduced. Staff feel supported by the digital system and report it to be helpful even during redeployment and in the unfamiliar environment of intensive care.
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Affiliation(s)
- Tanya Pankhurst
- Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Laurie Lucas
- IT Services, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Steve Ryan
- IT Services, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Chris Ragdale
- IT Services, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Helen Gyves
- IT Services, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Louise Denner
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ian Young
- IT Services, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Laura Rathbone
- IT Services, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Anwar Shah
- Anaesthetics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Deborah McKee
- IT Services, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jamie J Coleman
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK,School of Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Felicity Evison
- Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jolene Atia
- Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - David Rosser
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Mark Garrick
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard Baker
- Finance, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Suzy Gallier
- Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK,PIONEER: HDR-UK Health Data Research Hub in Acute care, University of Birmingham, Birmingham, UK
| | - Simon Ball
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK,Institute of Infection and Immunity, University of Birmingham, Birmingham, UK,Better Care, Health Data Research, London, UK
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18
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Marang-van de Mheen PJ, Woodcock T. Grand rounds in methodology: four critical decision points in statistical process control evaluations of quality improvement initiatives. BMJ Qual Saf 2023; 32:47-54. [PMID: 36109158 DOI: 10.1136/bmjqs-2022-014870] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 08/02/2022] [Indexed: 12/27/2022]
Abstract
Quality improvement (QI) projects often employ statistical process control (SPC) charts to monitor process or outcome measures as part of ongoing feedback, to inform successive Plan-Do-Study-Act cycles and refine the intervention (formative evaluation). SPC charts can also be used to draw inferences on effectiveness and generalisability of improvement efforts (summative evaluation), but only if appropriately designed and meeting specific methodological requirements for generalisability. Inadequate design decreases the validity of results, which not only reduces the chance of publication but could also result in patient harm and wasted resources if incorrect conclusions are drawn. This paper aims to bring together much of what has been written in various tutorials, to suggest a process for using SPC in QI projects. We highlight four critical decision points that are often missed, how these are inter-related and how they affect the inferences that can be drawn regarding effectiveness of the intervention: (1) the need for a stable baseline to enable drawing inferences on effectiveness; (2) choice of outcome measures to assess effectiveness, safety and intervention fidelity; (3) design features to improve the quality of QI projects; (4) choice of SPC analysis aligned with the type of outcome, and reporting on the potential influence of other interventions or secular trends.These decision points should be explicitly reported for readers to interpret and judge the results, and can be seen as supplementing the Standards for Quality Improvement Reporting Excellence guidelines. Thinking in advance about both formative and summative evaluation will inform more deliberate choices and strengthen the evidence produced by QI projects.
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Affiliation(s)
- Perla J Marang-van de Mheen
- Department of Biomedical Data Sciences, Medical Decision Making, J10-S, Leiden University Medical Center, Leiden, The Netherlands
| | - Thomas Woodcock
- National Institute for Health Research Applied Research Collaboration Northwest London, Imperial College London, London, UK
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19
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Seamark DA, Prodger E, Jay T, Gibbard E, Tucker H. Response of UK community hospitals to the COVID-19 pandemic: an appreciative inquiry. BMJ Open Qual 2022; 11:bmjoq-2022-001958. [PMID: 36207053 PMCID: PMC9556737 DOI: 10.1136/bmjoq-2022-001958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/23/2022] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The 500 community hospitals in the UK provide a range of services to their communities. The response of these small, mainly rural, hospitals to the COVID-19 pandemic has not yet been examined and so this study sought to address this gap. METHOD Appreciative inquiry was used to understand staff perspectives of how community hospitals responded to the COVID-19 (SARS-CoV-2) pandemic. A total of 20 organisations participated, representing 168 (34%) community hospitals in the UK. Qualitative interviews were conducted, with a total of 85 staff members, using an online video platform. 30 case studies were developed from these interviews. RESULTS Staff described positive changes that were made in the context of the fear and uncertainty experienced in the pandemic. Quality improvements were reported in a wide range of services and models of care such as the use of the inpatient beds, and the access and management of urgent care services. Rapid changes were made in the way that services were managed, such as communications and leadership. Programmes of accelerated training were offered for existing and redeployed staff. Attention to staff health and well-being was a feature and there were a variety of innovations designed to support patients and their families. The impact of the changes was viewed as strengthening of integrated working between staff and sectors, the ability to rapidly innovate and improve quality, and the scope to use local decision-making to make changes. CONCLUSION Staff of community hospitals described innovative and rapid quality improvements in their community hospitals in response to the pandemic. The case studies illustrated the features of community hospitals, showing that they can be resilient, flexible, responsive, creative, compassionate and integrated. The case studies of quality improvements are being used to encourage sharing and learning across community hospitals and beyond.
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Affiliation(s)
| | | | - Trish Jay
- Community Hospitals Association, Monmouth, UK
| | - Emma Gibbard
- Research and Innovations Services, University of Bath, Bath, UK
| | - Helen Tucker
- Health and Wellbeing Research Department, University of Winchester, Winchester, UK
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20
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Xu D, Lewis T, Rurka M, Arling G. Approach to systematically examine the usefulness of quality measures in practice: Minnesota's nursing home quality indicators and scoring approach. BMJ Qual Saf 2022; 32:319-329. [PMID: 36192147 DOI: 10.1136/bmjqs-2021-014384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 08/29/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Healthcare quality measurement systems, which use aggregated patient-level quality measures to assess organisational performance, have been introduced widely. Yet, their usefulness in practice has received scant attention. Using Minnesota nursing home quality indicators (QIs) as a case example, we demonstrate an approach for systematically evaluating QIs in practice based on: (a) parsimony and relevance, (b) usability in discriminating between facilities, (c) actionability and (d) construct validity. METHODS We analysed 19 risk-adjusted, facility-level QIs over the 2012-2019 period. Parsimony and relevance of QIs were evaluated using scatter plots, Pearson correlations, literature review and expert opinions. Discrimination between facilities was assessed by examining facility QI distributions and the impact of the distributions on scoring. Actionability of QIs was assessed through QI trends over time. Construct validity was assessed through exploratory factor analysis of domain structure for grouping the QIs. RESULTS Correlation analysis and qualitative assessment led to redefining one QI, adding one improvement-focused QI, and combining two highly correlated QIs to improve parsimony and clinical relevance. Ten of the QIs displayed normal distributions which discriminated well between the best and worst performers. The other nine QIs displayed poor discrimination; they had skewed distributions with ceiling or floor effects. We recommended scoring approaches tailored to these distributions. One QI displaying substantial improvement over time was recommended for retirement (physical restraint use). Based on factor analysis, we grouped the 18 final QIs into four domains: incontinence (4 QIs), physical functioning (4 QIs), psychosocial care (4 QIs) and care for specific conditions (6 QIs). CONCLUSION We demonstrated a systematic approach for evaluating QIs in practice by arriving at parsimonious and relevant QIs, tailored scoring to different QI distributions and a meaningful domain structure. This approach could be applied in evaluating quality measures in other health or long-term care settings.
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Affiliation(s)
- Dongjuan Xu
- School of Nursing, Purdue University, West Lafayette, Indiana, USA
| | - Teresa Lewis
- Nursing Facility Rates and Policy Division, Minnesota Department of Human Services, Saint Paul, Minnesota, USA
| | - Marissa Rurka
- Department of Sociology, Purdue University, West Lafayette, Indiana, USA
| | - Greg Arling
- School of Nursing, Purdue University, West Lafayette, Indiana, USA
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21
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Chen Y, Zhang Z, Gao C, Deng W, Chen W, Ao T. Quantitative analysis of soil sustainability after applying stabilizing amendments in long-term Cd-contaminated paddy soils. Environ Pollut 2021; 286:117205. [PMID: 33975219 DOI: 10.1016/j.envpol.2021.117205] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 04/13/2021] [Accepted: 04/17/2021] [Indexed: 06/12/2023]
Abstract
Considering the biomagnification in food chains, cadmium (Cd) contamination in paddy fields has become concerning. The remediation of soil cadmium by the addition of amendments is a common agricultural practice. However, it remains ambiguous whether amendment use decreases soil environmental quality (SEQ) and sustainability. In this study, five compound amendments with different pH were utilized in long-term Cd-contaminated paddy soils. The SEQ of all treatments was quantitatively assessed according to a comprehensive evaluation mathematical model (Criteria Importance Through Inter-criteria Correlation (CRITIC)-Technique for Order Preference by Similarity to Ideal Solution (TOPSIS)), and the indicators involved in microbial functional gene (MFG) abundance, soil physicochemical and microbiological properties (CMP) and soil microbial function (N-related enzyme and transformation rate, N-ET) were measured. The results show that the SQE and remediation effect (expressed by the decrease in available Cd (ACd), %) in our treatments were alkaline > natural > acidic except for D alkaline treatment. The significant contradiction between soil SQE and remediation effect in D treatment attribute to its dose effects, which inhibiting microbial nitrogen assimilation and dissimilation and therefore counteracts the promoting effect of the decrease in ACd. Based on this discussion, three alkaline amendments (A, B and D) with similar effective remediation effect were employed in four other Cd-contaminated soils. Results indicated that both negative effect (D treatment) and promoting effect (A and B treatment) existed in the next 3 years.
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Affiliation(s)
- Yi Chen
- College of Architecture and Environment, Sichuan University, Chengdu, Sichuan, 610065, China
| | - Zhe Zhang
- College of Architecture and Environment, Sichuan University, Chengdu, Sichuan, 610065, China
| | - Cheng Gao
- College of Architecture and Environment, Sichuan University, Chengdu, Sichuan, 610065, China
| | - Wenyang Deng
- College of Architecture and Environment, Sichuan University, Chengdu, Sichuan, 610065, China
| | - Wenqing Chen
- College of Architecture and Environment, Sichuan University, Chengdu, Sichuan, 610065, China.
| | - Tianqi Ao
- College of Water Resource & Hydropower, Sichuan University, Chengdu, Sichuan, 610065, China
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Ouayogodé MH, Meara E, Ho K, Snyder CM, Colla CH. Estimates of ACO savings in the presence of provider and beneficiary selection. Healthc (Amst) 2021; 9:100460. [PMID: 33412439 DOI: 10.1016/j.hjdsi.2020.100460] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/24/2020] [Accepted: 08/03/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Medicare's accountable care organizations (ACOs)-designed to improve quality and lower spending-were associated with growing savings in previous studies. However, savings estimates may be biased by beneficiary sorting among providers based on healthcare needs and by providers opting into the program based on anticipated gains. METHODS Using Medicare administrative claims (2009-2014), we compared annual spending changes after provider organizations joined ACOs to changes in non-ACOs (controls). To address provider selection, using novel data to identify non-ACO organizations, we restricted controls to comparably large provider organizations. To address beneficiary selection, we (a) estimated within-organization (including non-ACO comparison organizations) spending changes, (b) estimated within-beneficiary spending changes, (c) incorporated beneficiaries without qualifying healthcare expenses, and (d) used a fixed beneficiary ACO assignment using the pre-ACO period. RESULTS Each year, 19% of Medicare beneficiaries switched provider organizations. Spending was higher for switchers than stayers ($3163, p < .001) and grew more the next year ($2004; p < .001). Starting from a baseline regression modeled on previous ACO evaluations, estimated savings varied widely as we sequentially introduced methods to address selection. Combining methods, however, generated more stable estimated ACO savings of $46 (p = .022), averaged across cohorts. CONCLUSIONS When implementing a comprehensive suite of methods to adjust for provider and beneficiary selection, we estimated ACO savings that grew over time. Our estimates are in line with, but smaller than, previous estimates in the literature. Implementing piecemeal adjustments produced misleading results. IMPLICATIONS Our results confirm the importance of selection for savings estimates and for provider organizations managing costs and quality. Attribution rules that consider multiple years may help mitigate the impact of beneficiary churn for providers and payers. Implementing payment reform by randomizing early participants, or implementing fully across selected markets, may better serve efforts to evaluate and improve payment models. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
- Mariétou H Ouayogodé
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, 610 Walnut Street, Madison, WI, 53726, USA.
| | - Ellen Meara
- Harvard University, T.H. Chan School of Public Health, 677 Huntington Avenue Kresge, 4th Floor, Boston, Massachussetts, 02115, USA.
| | - Kate Ho
- Princeton University, Department of Economics, 285 Julis Romo Rabinowitz Building, Princeton, NJ, 08544, USA.
| | - Christopher M Snyder
- Dartmouth College, Department of Economics, 301 Rockefeller Hall, Hanover, NH, 03755, USA.
| | - Carrie H Colla
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Williamson Translational Research Building, Level 5, 1 Medical Center Drive, Lebanon, NH, 03756, USA.
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Cassetti V, Paredes-Carbonell JJ. [Theory of change: a tool for participatory planning and evaluation in community health]. Gac Sanit 2020; 34:305-7. [PMID: 31548017 DOI: 10.1016/j.gaceta.2019.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 06/04/2019] [Accepted: 06/07/2019] [Indexed: 11/21/2022]
Abstract
There is a growing interest in finding innovative approaches to the evaluation of complex interventions in public health. This methodological note presents the theory of change as a useful tool to facilitate both the planning and the evaluation of community health promotion interventions. A theory of change is a visual representation of how a programme or intervention works, in which its different components can be identified, together with how they relate to each other: what its objectives are, its expected results and through which actions they are expected to be achieved. It can be an applied research tool, developed using participatory approaches together with all relevant stakeholders, who can identify and jointly decide what to evaluate and how to.
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Li Y, Chen Y, Feng Q, Liu L, Wang J, Wei S, Feng X, Ran M, Jiang Y. Study of the adsorption mechanism on the surface of a ceramic nanomaterial for gaseous Hg(II) removal. Environ Sci Pollut Res Int 2019; 26:28294-28308. [PMID: 31368068 DOI: 10.1007/s11356-019-05631-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 05/29/2019] [Indexed: 06/10/2023]
Abstract
Stable Hg(II)-containing flue gas has been successfully simulated by the plasma oxidation of Hg(0), and an effective solution for Hg(0) mercury fumes was obtained by combining the plasma with a ceramic nanomaterial. Characterization tests showed that the ceramic nanomaterial was mainly composed of silicon dioxide (SiO2) with other minor constituents, including potassium mica (KAl3Si3O11), iron magnesium silicate (Fe0.24Mg0.76SiO3) and dolomite (CaMg(CO3)2). The nanomaterial had many tube bank structures inside with diameters of approximately 8-10 nm. The maximum sorption capacity of Hg(II) was 5156 μg/g, and the nanomaterial can be regenerated at least five times. During the adsorption, chemical adsorption first occurred between Hg(II) and sulfydryl moieties, but these were quickly exhausted, and Hg(II) was then removed by surface complexation and wrapped into Fe moieties. The pseudo-first-order kinetic model and the Langmuir equation had the best fitting results for the kinetics and isotherms of adsorption. This work suggests that the ceramic nanomaterial can be used as an effective and recyclable adsorbent in the removal of gaseous Hg(II).
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Affiliation(s)
- Yue Li
- Beijing Advanced Sciences and Innovation Center of CAS, Beijing, 101407, China
| | - Yang Chen
- Beijing Advanced Sciences and Innovation Center of CAS, Beijing, 101407, China.
| | - Qingzhong Feng
- Beijing Advanced Sciences and Innovation Center of CAS, Beijing, 101407, China
| | - Liyuan Liu
- Beijing Advanced Sciences and Innovation Center of CAS, Beijing, 101407, China
| | - Junfeng Wang
- Beijing Advanced Sciences and Innovation Center of CAS, Beijing, 101407, China
| | - Shihao Wei
- Beijing Advanced Sciences and Innovation Center of CAS, Beijing, 101407, China
| | - Xiangdong Feng
- Beijing Advanced Sciences and Innovation Center of CAS, Beijing, 101407, China
| | - Meixue Ran
- Beijing Advanced Sciences and Innovation Center of CAS, Beijing, 101407, China
| | - Yuanyuan Jiang
- Beijing Advanced Sciences and Innovation Center of CAS, Beijing, 101407, China
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Thompson MP, Graetz I, McKillop CN, Grubb PH, Waters TM. Evaluation of a Tennessee statewide initiative to reduce early elective deliveries using quasi-experimental methods. BMC Health Serv Res 2019; 19:208. [PMID: 30940130 PMCID: PMC6444673 DOI: 10.1186/s12913-019-4033-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 03/22/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Concerted quality improvement (QI) efforts have been taken to discourage the practice of early elective deliveries (EEDs), but few studies have robustly examined the impact of directed QI interventions in reducing EED practices. Using quasi-experimental methods, we sought to evaluate the impact of a statewide QI intervention to reduce the practice of EEDs. METHODS Retrospective cohort study of vital records data (2007 to 2013) for all singleton births occurring ≥36 weeks in 66 Tennessee hospitals grouped into three QI cohorts. We used interrupted-time series to estimate the effect of the QI intervention on the likelihood of an EED birth statewide, and by hospital cohort. We compared the distribution of hospital EED percentages pre- and post-intervention. Lastly, we used multivariable logistic regression to estimate the effect of QI interventions on maternal and infant outcomes. RESULTS Implementation of the QI intervention was associated with significant declines in likelihood of EEDs immediately following the intervention (odds ratio, OR = 0.72; p < 0.001), but these results varied by hospital cohort. Hospital risk-adjusted EED percentages ranged from 1.6-13.6% in the pre-intervention period, which significantly declined to 2.2-9.6% in the post-intervention period (p < 0.001). The QI intervention was also associated with significant reductions in operative vaginal delivery and perineal laceration, and immediate infant ventilation, but increased NICU admissions. CONCLUSIONS A statewide QI intervention to reduce EEDs was associated with modest but significant declines in EEDs beyond concurrent and national trends, and showed mixed results in related infant and maternal outcomes.
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Affiliation(s)
- Michael P Thompson
- Department of Preventive Medicine, University of Tennessee Health Science Center, 66 N Pauline, Memphis, TN, 38163, USA.
- Department of Cardiac Surgery, University of Michigan Medical School, 5331K Frankel Cardiovascular Center, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA.
| | - Ilana Graetz
- Department of Preventive Medicine, University of Tennessee Health Science Center, 66 N Pauline, Memphis, TN, 38163, USA
- Department of Health Policy and Management, Emory School of Public Health, 1518 Clifton Rd., NE, Suite 636, Atlanta, GA, 30322, USA
| | - Caitlin N McKillop
- Department of Preventive Medicine, University of Tennessee Health Science Center, 66 N Pauline, Memphis, TN, 38163, USA
- Department of Economics, SUNY Cortland, Old Main, Room 127, Gerhart Dr., Cortland, NY, 13045, USA
| | - Peter H Grubb
- Department of Pediatrics, Vanderbilt University School of Medicine, 2200 Children's Way, Nashville, TN, 37212, USA
- For the Tennessee Initiative for Perinatal Quality Care (TIPQC) Reducing Early Elective Deliveries Before 39 Weeks EGA Project, 2215B Garland Ave, Nashville, 37232, TN, USA
- Division of Neonatology, Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Teresa M Waters
- Department of Preventive Medicine, University of Tennessee Health Science Center, 66 N Pauline, Memphis, TN, 38163, USA
- Department of Health Management and Policy, University of Kentucky College of Public Health, 111 Washington Avenue, Lexington, KY, 40536, USA
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O'Neil G, Bauer MW. Pathways to use of communication campaigns' evaluation findings within international organizations. Eval Program Plann 2018; 69:82-91. [PMID: 29738897 DOI: 10.1016/j.evalprogplan.2018.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 04/28/2018] [Accepted: 04/29/2018] [Indexed: 06/08/2023]
Abstract
This article presents a study on the pathways and processes regarding the use of evaluation findings of communication campaigns from two international organizations, the Office of the High Commissioner for Human Rights (OHCHR) and the International Committee of the Red Cross (ICRC). Several years after the completion of the campaigns and their evaluations, our research identified 28 instances of use and six instances of non-use of the evaluation results, of which the large majority being surprising in nature. Results showed that evaluation use facilitated formal and informal changes at the individual and the organizational level; and, this pattern occurred in a predominantly non-linear fashion, interconnected and overlapping, while gradually decreasing in time and space. Evaluation use was mostly unpredictable, which reflected how meanings are constructed by staff members, as they adjusted and interpreted the findings in opportunistic ways.
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Affiliation(s)
- Glenn O'Neil
- Owl RE, Research and Evaluation Consultancy, Geneva, Switzerland.
| | - Martin W Bauer
- Social Psychology and Research Methodology, London School of Economics and Political Science, London, UK.
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27
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Lee SJC, Inrig SJ, Balasubramanian BA, Skinner CS, Higashi RT, McCallister K, Bishop WP, Santini NO, Tiro JA. Identifying quality improvement targets to facilitate colorectal cancer screening completion. Prev Med Rep 2018. [PMID: 29527466 PMCID: PMC5840842 DOI: 10.1016/j.pmedr.2018.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The colorectal cancer (CRC) screening process involves multiple interfaces (communication exchanges and transfers of responsibility for specific actions) among primary care and gastroenterology providers, laboratory, and administrative staff. After a retrospective electronic health record (EHR) analysis discovered substantial clinic variation and low CRC screening prevalence overall in an urban, integrated safety-net system, we launched a qualitative analysis to identify potential quality improvement targets to enhance fecal immunochemical test (FIT) completion, the system's preferred screening modality. Here, we report examination of organization-, clinic-, and provider-level interfaces over a three-year period (December 2011–October 2014). We deployed in parallel 3 qualitative data collection methods: (1) structured observation (90+ hours, 10 sites); (2) document analysis (n > 100); and (3) semi-structured interviews (n = 41) and conducted iterative thematic analysis in which findings from each method cross-informed subsequent data collection. Thematic analysis was guided by a conceptual model and applied deductive and inductive codes. There was substantial variation in protocols for distributing and returning FIT kits both within and across clinics. Providers, clinic and laboratory staff had differing access to important data about FIT results based on clinical information system used and this affected results reporting. Communication and coordination during electronic referrals for diagnostic colonoscopy was suboptimal particularly for co-morbid patients needing anesthesia clearance. Our multi-level approach elucidated organizational deficiencies not evident by quantitative analysis alone. Findings indicate potential quality improvement intervention targets including: (1) best-practices implementation across clinics; (2) detailed communication to providers about FIT results; and (3) creation of EHR alerts to resolve pending colonoscopy referrals before they expire. Multi-level qualitative approach identified challenges to 3 clinical processes Variation in fecal immunochemical testing (FIT) kit distribution and return Incomplete transfer of key FIT result data across clinical information systems Suboptimal communication and coordination during colonoscopy referrals
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Affiliation(s)
- Simon J Craddock Lee
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA.,Harold C. Simmons Comprehensive Cancer Center, Dallas, TX, USA
| | - Stephen J Inrig
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA.,Mount St. Mary's University, Los Angeles, CA, USA
| | - Bijal A Balasubramanian
- Harold C. Simmons Comprehensive Cancer Center, Dallas, TX, USA.,Department of Epidemiology, Human Genetics, and Environmental Sciences, UT Health School of Public Health - Dallas Campus, Dallas, TX, USA
| | - Celette Sugg Skinner
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA.,Harold C. Simmons Comprehensive Cancer Center, Dallas, TX, USA
| | - Robin T Higashi
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA
| | | | - Wendy Pechero Bishop
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA.,Harold C. Simmons Comprehensive Cancer Center, Dallas, TX, USA
| | | | - Jasmin A Tiro
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA.,Harold C. Simmons Comprehensive Cancer Center, Dallas, TX, USA
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Gurari N, Drogos JM, Lopez S, Dewald JPA. Impact of motor task execution on an individual's ability to mirror forearm positions. Exp Brain Res 2018; 236:765-77. [PMID: 29330571 DOI: 10.1007/s00221-018-5173-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 01/05/2018] [Indexed: 10/18/2022]
Abstract
This work is motivated by our goal of determining why individuals with stroke are impaired when locating their arms in space. We assessed the ability of individuals without neurological impairments to mirror their forearms during various motor tasks so that we could identify baseline performance in an unimpaired population. Nine right-hand dominant participants without neurological impairments mirrored forearm positions bi-directionally (i.e., right forearm mirrors left forearm, vice versa) for three motor tasks (i.e., passive, passive/active, and active) and two position identification modes (i.e., mirroring to a position stored in working memory versus concurrently felt by the opposite arm). During each trial, the participant's reference forearm moved to a flexion ([Formula: see text]) or extension ([Formula: see text]) position, and then, their opposite forearm mirrored the position of their reference forearm. The main finding across all tested conditions is that participants mirrored forearm positions with an average magnitude of error [Formula: see text]. When controlling their forearms' movements (active motor task), participants mirrored forearm positions more accurately by up to, on average, [Formula: see text] at the flexion location than at the extension location. Moreover, participants mirrored forearm positions more accurately by up to, on average, [Formula: see text] when their forearms were moved for them rather than when they controlled their forearms' movements. Task directionality and position identification mode did not significantly affect participant arm mirroring accuracy. These findings are relevant for interpreting in future work the reason why impairments occur, on similar tasks, in individuals with altered motor commands, working memory, and arm impedance, e.g., post-stroke hemiparesis.
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Dalmago GA, da Cunha GR, Santi A, Fochesatto E, Kovaleski S. Representativeness of Scholander chamber measurements as a function of time after leaf removal. Int J Biometeorol 2017; 61:1699-1701. [PMID: 28386701 DOI: 10.1007/s00484-017-1351-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 04/01/2017] [Accepted: 04/01/2017] [Indexed: 06/07/2023]
Abstract
The objectives of the study were to determine the maximum tolerable period between leaf removal from a plant and the determination of leaf water potential (Ψ l ), and to evaluate different ways of packing leaves after their removal from a plant (LR). Two experiments (Exp) were conducted in a randomized complete block design with four replicates, using bean, maize, and soybean crops. The predawn leaf water potential (Ψ PD ) (Exp1) and the minimum leaf water potential (Ψ min ) (Exp1 and Exp2) were determined. The maximum tolerable period between LR varied among species, ranging from 80 to 90 min for bean and soybean, and from 40 to 60 min for maize. A box with low interior air temperature and capable of blocking the effect of solar radiation reduced variation in leaf water potential. These results indicate that the determination of the Ψ l in bean, soybean, and maize crops does not need to be carried out immediately after leaf removal.
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Affiliation(s)
- Genei Antonio Dalmago
- Embrapa Trigo, Caixa Postal 3081, Passo Fundo, RS, CEP 99050-970, Brazil.
- Fellowship Productivity in Research National Counsel of Technological and Scientific Development (CNPq), Brasília, Brazil.
| | | | - Anderson Santi
- Embrapa Trigo, Caixa Postal 3081, Passo Fundo, RS, CEP 99050-970, Brazil
| | | | - Samuel Kovaleski
- Embrapa Trigo, Caixa Postal 3081, Passo Fundo, RS, CEP 99050-970, Brazil
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Tevendale HD, Condron DS, Garraza LG, House LD, Romero LM, Brooks MAM, Walrath C. Practical Approaches to Evaluating Progress and Outcomes in Community-Wide Teen Pregnancy Prevention Initiatives. J Adolesc Health 2017; 60:S63-S68. [PMID: 28235438 DOI: 10.1016/j.jadohealth.2016.09.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 09/16/2016] [Accepted: 09/19/2016] [Indexed: 10/20/2022]
Abstract
This paper presents an overview of the key evaluation components for a set of community-wide teen pregnancy prevention initiatives. We first describe the performance measures selected to assess progress toward meeting short-term objectives on the reach and quality of implementation of evidence-based teen pregnancy prevention interventions and adolescent reproductive health services. Next, we describe an evaluation that will compare teen birth rates in intervention communities relative to synthetic control communities. Synthetic controls are developed via a data-driven technique that constructs control communities by combining information from a pool of communities that are similar to the intervention community. Finally, we share lessons learned thus far in the evaluation of the project, with a focus on those lessons that may be valuable for local communities evaluating efforts to reduce teen pregnancy.
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Affiliation(s)
- Heather D Tevendale
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | | | | | - L Duane House
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lisa M Romero
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Eyre L, Farrelly M, Marshall M. What can a participatory approach to evaluation contribute to the field of integrated care? BMJ Qual Saf 2016; 26:588-594. [PMID: 27932546 DOI: 10.1136/bmjqs-2016-005777] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 10/26/2016] [Accepted: 11/13/2016] [Indexed: 11/03/2022]
Abstract
Better integration of care within the health sector and between health and social care is seen in many countries as an essential way of addressing the enduring problems of dwindling resources, changing demographics and unacceptable variation in quality of care. Current research evidence about the effectiveness of integration efforts supports neither the enthusiasm of those promoting and designing integrated care programmes nor the growing efforts of practitioners attempting to integrate care on the ground. In this paper we present a methodological approach, based on the principles of participatory research, that attempts to address this challenge. Participatory approaches are characterised by a desire to use social science methods to solve practical problems and a commitment on the part of researchers to substantive and sustained collaboration with relevant stakeholders. We describe how we applied an emerging practical model of participatory research, the researcher-in-residence model, to evaluate a large-scale integrated care programme in the UK. We propose that the approach added value to the programme in a number of ways: by engaging stakeholders in using established evidence and with the benefits of rigorously evaluating their work, by providing insights for local stakeholders that they were either not familiar with or had not fully considered in relation to the development and implementation of the programme and by challenging established mindsets and norms. While there is still much to learn about the benefits and challenges of applying participatory approaches in the health sector, we demonstrate how using such approaches have the potential to help practitioners integrate care more effectively in their daily practice and help progress the academic study of integrated care.
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Affiliation(s)
- Laura Eyre
- Reserach Department of Primary Care and Population Health, University College London, London, UK
| | - Michael Farrelly
- School of Histories, Languages and Cultures, University of Hull, Hull, UK
| | - Martin Marshall
- Reserach Department of Primary Care and Population Health, University College London, London, UK
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Gurari N, Drogos JM, Dewald JPA. Individuals with chronic hemiparetic stroke can correctly match forearm positions within a single arm. Clin Neurophysiol 2016; 128:18-30. [PMID: 27866116 DOI: 10.1016/j.clinph.2016.10.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 10/03/2016] [Accepted: 10/09/2016] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Previous studies determined, using between arms position matching assessments, that at least one-half of individuals with stroke have an impaired position sense. We investigated whether individuals with chronic stroke who have impairments mirroring arm positions also have impairments identifying the location of each arm in space. METHODS Participants with chronic hemiparetic stroke and age-matched participants without neurological impairments (controls) performed a between forearms position matching task based on a clinical assessment and a single forearm position matching task, using passive and active movements, based on a robotic assessment. RESULTS 12 out of our 14 participants with stroke who had clinically determined between forearms position matching impairments had greater errors than the controls in both their paretic and non-paretic arm when matching positions during passive movements; yet stroke participants performed comparable to the controls during active movements. CONCLUSIONS Many individuals with chronic stroke may have impairments matching positions in both their paretic and non-paretic arm if their arm is moved for them, yet not within either arm if these individuals control their own movements. SIGNIFICANCE The neural mechanisms governing arm location perception in the stroke population may differ depending on whether arm movements are made passively versus actively.
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Affiliation(s)
- Netta Gurari
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL 60611, United States.
| | - Justin M Drogos
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL 60611, United States.
| | - Julius P A Dewald
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL 60611, United States; Department of Biomedical Engineering, Northwestern University, Evanston, IL 60208, United States; Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL 60611, United States; Department of Biomechanical Engineering, Faculty of Engineering Technology, University of Twente, Enschede, The Netherlands.
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Abstract
Quality improvement (QI) efforts affect a broader range of people than we often assume. These are the potential stakeholders for QI and its evaluation, and they have valuable perspectives to offer when they are consulted in planning, conducting and interpreting evaluations. QI practitioners are accustomed to consulting stakeholders to assess unintended consequences or assess patient experiences of care, but in many cases there are additional benefits to a broad inclusion of stakeholders. These benefits are better adherence to ethical standards, to assure that all legitimate interests take part, more useful and relevant evaluation information and better political buy-in to improve impact. Balancing various stakeholder needs for information requires skill for both politics and research management. These challenges have few pat answers, but several preferred practices, which are illustrated with practical examples.
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Affiliation(s)
- Laura C Leviton
- The Robert Wood Johnson Foundation, Research, Evaluation and Learning, Princeton, New Jersey, USA
| | - Lori Melichar
- The Robert Wood Johnson Foundation, Research, Evaluation and Learning, Princeton, New Jersey, USA
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Affiliation(s)
- Paul M Wilson
- Manchester Business School, University of Manchester, Manchester, UK
| | - Ruth Boaden
- Manchester Business School, University of Manchester, Manchester, UK
| | - Gillian Harvey
- Manchester Business School, University of Manchester, Manchester, UK School of Nursing, University of Adelaide, Adelaide, Australia
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35
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Parry G, Power M. To RCT or not to RCT? The ongoing saga of randomised trials in quality improvement. BMJ Qual Saf 2015; 25:221-3. [PMID: 26545704 DOI: 10.1136/bmjqs-2015-004862] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 10/15/2015] [Indexed: 11/03/2022]
Affiliation(s)
- Gareth Parry
- Institute for Healthcare Improvement, Cambridge, Massachusetts, USA
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Abstract
Background When patient safety climate (PSC) surveys are used in healthcare, reporting typically focuses on PSC level (mean or per cent positive scores). This paper explores how an additional focus on PSC strength can enhance the utility of PSC survey data. Setting and participants 442 care providers from 24 emergency departments (EDs) across Canada. Methods We use anonymised data from the Can-PSCS PSC instrument collected in 2011 as part of the Qmentum accreditation programme. We examine differences in climate strength across EDs using the Rwg(j) and intraclass correlation coefficients measures of inter-rater agreement. Results Across the six survey dimensions, median Rwg(j) was sufficiently high to support shared climate perceptions (0.64–0.83), but varied widely across the 24 ED units. We provide an illustrative example showing vastly different climate strength (Rwg(j) range=0.17–0.86) for units with an equivalent level of PSC (eg, climate mean score=3). Conclusions Most PSC survey results focus solely on climate level. To facilitate improvement in PSC, we advocate a simple, holistic safety climate profile including three metrics: climate level (using mean or per cent positive climate scores), climate strength (using the Rwg(j), or SD as a proxy) and the shape of the distribution (using histograms to see the distribution of scores within units). In PSC research, we advocate paying attention to climate strength as an important variable in its own right. Focusing on PSC level and strength can further understanding of the extent to which PSC is a key variable in the domain of patient safety.
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Affiliation(s)
- Liane Ginsburg
- School of Health Policy & Management, York University, Toronto, Ontario, Canada
| | - Debra Gilin Oore
- Department of Psychology, Saint Mary's University, Halifax, Nova Scotia, Canada
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Chen YF, Hemming K, Stevens AJ, Lilford RJ. Secular trends and evaluation of complex interventions: the rising tide phenomenon. BMJ Qual Saf 2015; 25:303-10. [PMID: 26442789 PMCID: PMC4853562 DOI: 10.1136/bmjqs-2015-004372] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 09/13/2015] [Indexed: 11/19/2022]
Abstract
Evaluations of service delivery interventions with contemporaneous controls often yield null results, even when the intervention appeared promising in advance. There can be many reasons for null results. In this paper we introduce the concept of a ‘rising tide’ phenomenon being a possible explanation of null results. We note that evaluations of service delivery interventions often occur when awareness of the problems they intend to address is already heightened, and pressure to tackle them is mounting throughout a health system. An evaluation may therefore take place in a setting where the system as a whole is improving – where there is a pronounced temporal trend or a ‘rising tide causing all vessels to rise’. As a consequence, control sites in an intervention study will improve. This reduces the difference between intervention and control sites and predisposes the study to a null result, leading to the conclusion that the intervention has no effect. We discuss how a rising tide may be distinguished from other causes of improvement in both control and intervention groups, and give examples where the rising tide provides a convincing explanation of such a finding. We offer recommendations for interpretation of research findings where improvements in the intervention group are matched by improvements in the control group. Understanding the rising tide phenomenon is important for a more nuanced interpretation of null results arising in the context of system-wide improvement. Recognition that a rising tide may have predisposed to a null result in one health system cautions against generalising the result to another health system where strong secular trends are absent.
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Affiliation(s)
- Yen-Fu Chen
- Warwick Centre for Applied Health Research & Delivery, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Karla Hemming
- School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Andrew J Stevens
- School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Richard J Lilford
- Warwick Centre for Applied Health Research & Delivery, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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Hempel S, Shekelle PG, Liu JL, Sherwood Danz M, Foy R, Lim YW, Motala A, Rubenstein LV. Development of the Quality Improvement Minimum Quality Criteria Set (QI-MQCS): a tool for critical appraisal of quality improvement intervention publications. BMJ Qual Saf 2015; 24:796-804. [PMID: 26311020 PMCID: PMC4680162 DOI: 10.1136/bmjqs-2014-003151] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 04/22/2015] [Indexed: 11/30/2022]
Abstract
Objective Valid, reliable critical appraisal tools advance quality improvement (QI) intervention impacts by helping stakeholders identify higher quality studies. QI approaches are diverse and differ from clinical interventions. Widely used critical appraisal instruments do not take unique QI features into account and existing QI tools (eg, Standards for QI Reporting Excellence) are intended for publication guidance rather than critical appraisal. This study developed and psychometrically tested a critical appraisal instrument, the QI Minimum Quality Criteria Set (QI-MQCS) for assessing QI-specific features of QI publications. Methods Approaches to developing the tool and ensuring validity included a literature review, in-person and online survey expert panel input, and application to empirical examples. We investigated psychometric properties in a set of diverse QI publications (N=54) by analysing reliability measures and item endorsement rates and explored sources of disagreement between reviewers. Results The QI-MQCS includes 16 content domains to evaluate QI intervention publications: Organisational Motivation, Intervention Rationale, Intervention Description, Organisational Characteristics, Implementation, Study Design, Comparator Description, Data Sources, Timing, Adherence/Fidelity, Health Outcomes, Organisational Readiness, Penetration/Reach, Sustainability, Spread and Limitations. Median inter-rater agreement for QI-MQCS items was κ 0.57 (83% agreement). Item statistics indicated sufficient ability to differentiate between publications (median quality criteria met 67%). Internal consistency measures indicated coherence without excessive conceptual overlap (absolute mean interitem correlation=0.19). The critical appraisal instrument is accompanied by a user manual detailing What to consider, Where to look and How to rate. Conclusions We developed a ready-to-use, valid and reliable critical appraisal instrument applicable to healthcare QI intervention publications, but recognise scope for continuing refinement.
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Affiliation(s)
| | - Paul G Shekelle
- RAND Corporation, Santa Monica, California, USA Veterans Affairs West Los Angeles Medical Center, Los Angeles, California, USA
| | - Jodi L Liu
- RAND Corporation, Santa Monica, California, USA
| | - Margie Sherwood Danz
- RAND Corporation, Santa Monica, California, USA Veterans Affairs Greater Los Angeles, North Hills, California, USA
| | - Robbie Foy
- University of Leeds, Leeds Institute of Health Sciences, Leeds, UK
| | - Yee-Wei Lim
- National University of Singapore, Saw Swee Hock School of Public Health, Singapore
| | | | - Lisa V Rubenstein
- RAND Corporation, Santa Monica, California, USA Veterans Affairs Greater Los Angeles, North Hills, California, USA University of California, Department of Medicine, Los Angeles, California, USA
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Booth A, Carroll C. How to build up the actionable knowledge base: the role of 'best fit' framework synthesis for studies of improvement in healthcare. BMJ Qual Saf 2015; 24:700-8. [PMID: 26306609 PMCID: PMC4680127 DOI: 10.1136/bmjqs-2014-003642] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 04/17/2015] [Indexed: 12/21/2022]
Abstract
Increasing recognition of the role and value of theory in improvement work in healthcare offers the prospect of capitalising upon, and consolidating, actionable lessons from synthesis of improvement projects and initiatives. We propose that informed use of theory can (i) provide a mechanism by which to collect and organise data from a body of improvement work, (ii) offer a framework for analysis and identification of lessons learnt and (iii) facilitate an evaluation of the feasibility, effectiveness and acceptability of improvement programmes. Improvement practitioners can benefit from using an underpinning external structure as a lens by which to examine the specific achievements of their own projects alongside comparable initiatives led by others. We demonstrate the utility of a method known as ‘best fit framework synthesis’ (BFFS) in offering a ubiquitous and versatile means by which to collect, analyse and evaluate improvement work in healthcare. First reported in 2011, BFFS represents a pragmatic, flexible approach to integrating theory with findings from practice. A deductive phase, where a review team seeks to accommodate a substantial part of the data, is followed by an inductive phase, in which the team explores data not accommodated by the framework. We explore the potential for BFFS within improvement work by drawing upon the evidence synthesis methodology literature and practical examples of improvement work reported in BMJ Quality and Safety (2011–2015). We suggest four variants of BFFS that may have particular value in synthesising a body of improvement work. We conclude that BFFS, alongside other approaches that seek to optimise the contribution of theory to improvement work, represents one important enabling mechanism by which to establish the rigour and scientific credentials of the emerging discipline of ‘improvement science’.
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Affiliation(s)
- Andrew Booth
- School of Health & Related Research (ScHARR), University of Sheffield, Sheffield, South Yorkshire, UK
| | - Christopher Carroll
- School of Health & Related Research (ScHARR), University of Sheffield, Sheffield, South Yorkshire, UK
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Abstract
Improvement (defined broadly as purposive efforts to secure positive change) has become an increasingly important activity and field of inquiry within healthcare. This article offers an overview of possible methods for the study of improvement interventions. The choice of available designs is wide, but debates continue about how far improvement efforts can be simultaneously practical (aimed at producing change) and scientific (aimed at producing new knowledge), and whether the distinction between the practical and the scientific is a real and useful one. Quality improvement projects tend to be applied and, in some senses, self-evaluating. They are not necessarily directed at generating new knowledge, but reports of such projects if well conducted and cautious in their inferences may be of considerable value. They can be distinguished heuristically from research studies, which are motivated by and set out explicitly to test a hypothesis, or otherwise generate new knowledge, and from formal evaluations of improvement projects. We discuss variants of trial designs, quasi-experimental designs, systematic reviews, programme evaluations, process evaluations, qualitative studies, and economic evaluations. We note that designs that are better suited to the evaluation of clearly defined and static interventions may be adopted without giving sufficient attention to the challenges associated with the dynamic nature of improvement interventions and their interactions with contextual factors. Reconciling pragmatism and research rigour is highly desirable in the study of improvement. Trade-offs need to be made wisely, taking into account the objectives involved and inferences to be made.
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Affiliation(s)
- Margareth Crisóstomo Portela
- Social Science Applied to Healthcare Research (SAPPHIRE) Group, Department of Health Sciences, School of Medicine, University of Leicester, Leicester, UK Department of Health Administration and Planning, National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, RJ, Brazil
| | - Peter J Pronovost
- Departments of Anesthesiology, Critical Care Medicine, and Surgery, Armstrong Institute for Patient Safety and Quality, School of Medicine, and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Thomas Woodcock
- NIHR CLAHRC for Northwest London, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Pam Carter
- Social Science Applied to Healthcare Research (SAPPHIRE) Group, Department of Health Sciences, School of Medicine, University of Leicester, Leicester, UK
| | - Mary Dixon-Woods
- Social Science Applied to Healthcare Research (SAPPHIRE) Group, Department of Health Sciences, School of Medicine, University of Leicester, Leicester, UK
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Wandersman A, Alia KA, Cook B, Ramaswamy R. Integrating empowerment evaluation and quality improvement to achieve healthcare improvement outcomes. BMJ Qual Saf 2015; 24:645-52. [PMID: 26178332 PMCID: PMC4602254 DOI: 10.1136/bmjqs-2014-003525] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 06/25/2015] [Indexed: 01/01/2023]
Abstract
While the body of evidence-based healthcare interventions grows, the ability of health systems to deliver these interventions effectively and efficiently lags behind. Quality improvement approaches, such as the model for improvement, have demonstrated some success in healthcare but their impact has been lessened by implementation challenges. To help address these challenges, we describe the empowerment evaluation approach that has been developed by programme evaluators and a method for its application (Getting To Outcomes (GTO)). We then describe how GTO can be used to implement healthcare interventions. An illustrative healthcare quality improvement example that compares the model for improvement and the GTO method for reducing hospital admissions through improved diabetes care is described. We conclude with suggestions for integrating GTO and the model for improvement.
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Affiliation(s)
- Abraham Wandersman
- Department of Psychology, University of South Carolina, Columbia, South Carolina, USA
| | - Kassandra Ann Alia
- Department of Psychology, University of South Carolina, Columbia, South Carolina, USA
| | - Brittany Cook
- Public Health Leadership, UNC Chapel Hill, Chapel Hill, North Carolina, USA
| | - Rohit Ramaswamy
- Public Health Leadership, UNC Chapel Hill, Chapel Hill, North Carolina, USA
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Abstract
International travel, medical tourism and trade have created a demand for reliable assessment of healthcare provision across borders, and for information which is accessible to patients, insurers and referring institutions. External assessment schemes for healthcare providers may be clustered into three types: statutory regulation and institutional licensing, International Standardization Organisation certification, and voluntary systems such as peer review and healthcare accreditation. Increasing complexity of healthcare provision, pressures for public accountability and expectations of professional self-governance place a burden on the inspectors and the inspected. If only to contain costs of external assessment and to increase access to reliable information for patients and insurers, the three approaches must work together rather than compete. This paper summarises the origins, aims, authority and methods of the three general models, describing current pressures and opportunities for convergence (between systems and across borders) in the UK and in Europe.
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43
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Brewster L, Aveling EL, Martin G, Tarrant C, Dixon-Woods M. What to expect when you're evaluating healthcare improvement: a concordat approach to managing collaboration and uncomfortable realities. BMJ Qual Saf 2015; 24:318-24. [PMID: 25838466 PMCID: PMC4413682 DOI: 10.1136/bmjqs-2014-003732] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 03/17/2015] [Indexed: 11/15/2022]
Abstract
Evaluation of improvement initiatives in healthcare is essential to establishing whether interventions are effective and to understanding how and why they work in order to enable replication. Although valuable, evaluation is often complicated by tensions and friction between evaluators, implementers and other stakeholders. Drawing on the literature, we suggest that these tensions can arise from a lack of shared understanding of the goals of the evaluation; confusion about roles, relationships and responsibilities; data burdens; issues of data flows and confidentiality; the discomforts of being studied and the impact of disappointing or otherwise unwelcome results. We present a possible approach to managing these tensions involving the co-production and use of a concordat. We describe how we developed a concordat in the context of an evaluation of a complex patient safety improvement programme known as Safer Clinical Systems Phase 2. The concordat development process involved partners (evaluators, designers, funders and others) working together at the outset of the project to agree a set of principles to guide the conduct of the evaluation. We suggest that while the concordat is a useful resource for resolving conflicts that arise during evaluation, the process of producing it is perhaps even more important, helping to make explicit unspoken assumptions, clarify roles and responsibilities, build trust and establish open dialogue and shared understanding. The concordat we developed established some core principles that may be of value for others involved in evaluation to consider. But rather than seeing our document as a ready-made solution, there is a need for recognition of the value of the process of co-producing a locally agreed concordat in enabling partners in the evaluation to work together effectively.
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Affiliation(s)
- Liz Brewster
- Department of Health Sciences, University of Leicester, Leicester, UK
| | | | - Graham Martin
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Carolyn Tarrant
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Mary Dixon-Woods
- Department of Health Sciences, University of Leicester, Leicester, UK
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Portela MC, Pronovost PJ, Woodcock T, Carter P, Dixon-Woods M. How to study improvement interventions: a brief overview of possible study types. BMJ Qual Saf 2015; 24:325-36. [PMID: 25810415 PMCID: PMC4413733 DOI: 10.1136/bmjqs-2014-003620] [Citation(s) in RCA: 176] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 02/16/2015] [Indexed: 12/16/2022]
Abstract
Improvement (defined broadly as purposive efforts to secure positive change) has become an increasingly important activity and field of inquiry within healthcare. This article offers an overview of possible methods for the study of improvement interventions. The choice of available designs is wide, but debates continue about how far improvement efforts can be simultaneously practical (aimed at producing change) and scientific (aimed at producing new knowledge), and whether the distinction between the practical and the scientific is a real and useful one. Quality improvement projects tend to be applied and, in some senses, self-evaluating. They are not necessarily directed at generating new knowledge, but reports of such projects if well conducted and cautious in their inferences may be of considerable value. They can be distinguished heuristically from research studies, which are motivated by and set out explicitly to test a hypothesis, or otherwise generate new knowledge, and from formal evaluations of improvement projects. We discuss variants of trial designs, quasi-experimental designs, systematic reviews, programme evaluations, process evaluations, qualitative studies, and economic evaluations. We note that designs that are better suited to the evaluation of clearly defined and static interventions may be adopted without giving sufficient attention to the challenges associated with the dynamic nature of improvement interventions and their interactions with contextual factors. Reconciling pragmatism and research rigour is highly desirable in the study of improvement. Trade-offs need to be made wisely, taking into account the objectives involved and inferences to be made.
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Affiliation(s)
- Margareth Crisóstomo Portela
- Social Science Applied to Healthcare Research (SAPPHIRE) Group, Department of Health Sciences, School of Medicine, University of Leicester, Leicester, UK Department of Health Administration and Planning, National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, RJ, Brazil
| | - Peter J Pronovost
- Departments of Anesthesiology, Critical Care Medicine, and Surgery, Armstrong Institute for Patient Safety and Quality, School of Medicine, and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Thomas Woodcock
- NIHR CLAHRC for Northwest London, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Pam Carter
- Social Science Applied to Healthcare Research (SAPPHIRE) Group, Department of Health Sciences, School of Medicine, University of Leicester, Leicester, UK
| | - Mary Dixon-Woods
- Social Science Applied to Healthcare Research (SAPPHIRE) Group, Department of Health Sciences, School of Medicine, University of Leicester, Leicester, UK
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Abstract
The role and value of theory in improvement work in healthcare has been seriously underrecognised. We join others in proposing that more informed use of theory can strengthen improvement programmes and facilitate the evaluation of their effectiveness. Many professionals, including improvement practitioners, are unfortunately mystified-and alienated-by theory, which discourages them from using it in their work. In an effort to demystify theory we make the point in this paper that, far from being discretionary or superfluous, theory ('reason-giving'), both informal and formal, is intimately woven into virtually all human endeavour. We explore the special characteristics of grand, mid-range and programme theory; consider the consequences of misusing theory or failing to use it; review the process of developing and applying programme theory; examine some emerging criteria of 'good' theory; and emphasise the value, as well as the challenge, of combining informal experience-based theory with formal, publicly developed theory. We conclude that although informal theory is always at work in improvement, practitioners are often not aware of it or do not make it explicit. The germane issue for improvement practitioners, therefore, is not whether they use theory but whether they make explicit the particular theory or theories, informal and formal, they actually use.
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Affiliation(s)
- Frank Davidoff
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | | | - Laura Leviton
- Robert Wood Johnson Foundation, Princeton, New Jersey, USA
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Reed JE, McNicholas C, Woodcock T, Issen L, Bell D. Designing quality improvement initiatives: the action effect method, a structured approach to identifying and articulating programme theory. BMJ Qual Saf 2014; 23:1040-8. [PMID: 25319412 DOI: 10.1136/bmjqs-2014-003103] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND The identification and articulation of programme theory can support effective design, execution and evaluation of quality improvement (QI) initiatives. Programme theory includes an agreed aim, potential interventions to achieve this aim, anticipated cause/effect relationships between the interventions and the aim and measures to monitor improvement. This paper outlines the approach used in a research and improvement programme to support QI initiatives in identifying and articulating programme theory: the action effect method. BACKGROUND TO METHOD DEVELOPMENT Building on a previously used QI method, the driver diagram, the action effect method was developed using co-design and iteration over four annual rounds of improvement initiatives. This resulted in a specification of the elements required to fully articulate the programme theory of a QI initiative. THE ACTION EFFECT METHOD The action effect method is a systematic and structured process to identify and articulate a QI initiative's programme theory. The method connects potential interventions and implementation activities with an overall improvement aim through a diagrammatic representation of hypothesised and evidenced cause/effect relationships. Measure concepts, in terms of service delivery and patient and system outcomes, are identified to support evaluation. DISCUSSION AND CONCLUSIONS The action effect method provides a framework to guide the execution and evaluation of a QI initiative, a focal point for other QI methods and a communication tool to engage stakeholders. A clear definition of what constitutes a well-articulated programme theory is provided to guide the use of the method and assessment of the fidelity of its application.
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Affiliation(s)
- Julie E Reed
- NIHR CLAHRC NWL, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | | | - Thomas Woodcock
- NIHR CLAHRC NWL, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Laurel Issen
- NIHR CLAHRC NWL, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Derek Bell
- NIHR CLAHRC NWL, Imperial College London, Chelsea and Westminster Hospital, London, UK
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Abstract
BACKGROUND Reducing time-to-care is crucial in many acute and chronic diseases. Quality indicators based on target delays derived from guidelines are used to compare hospital performance but there is no accepted methodology for comparing performance when no target delay has been established. AIM To explore by different statistical methods the uncertainty in hospital comparisons that are based on delay indicators, when no target delay is available. METHODS Data for hospital door-to-needle time were extracted from a 2010 study of 1699 patients in 57 hospitals with ST-elevated myocardial infarction. We determined whether the times in each hospital were statistically different from the overall mean time or the median time for all hospitals by (i) one-way analysis of variance (ANOVA), (ii) non-parametric ANOVA with Nelson-Hsu adjustment (ANOVA R) and (iii) the proportional hazard model (PHM). We also tested for the assumptions underlying the methods: normal distribution for ANOVA, homogeneity of variances (homoscedasticity) for ANOVA and ANOVA R, and proportionality for PHM. RESULTS Door-to-needle times were available for 889 patients in 44 hospitals. Data distribution was not Gaussian. Test assumptions were verified for ANOVA R (homoscedasticity) for one data subset (>48-h times (48H) excluded) and for PHM (proportionality) for two data subsets (48H or >95th percentile (P95) times excluded). The same five significantly better performers were identified in each case (although ANOVA R missed one). ANOVA R (48H) identified two significantly poorer performers, PHM (48H) identified three and PHM (P95) just one. Poorer performers differed according to method. CONCLUSIONS The tested statistical methods yielded broadly similar results but no method was truly satisfactory. A transparency statement should therefore always specify the ranking method used to compare hospital performance.
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Affiliation(s)
- Henri Leleu
- COMPAQ-HPST, Institut Gustave Roussy, , Villejuif, France
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Mate KS, Ngidi WH, Reddy J, Mphatswe W, Rollins N, Barker P. A case report of evaluating a large-scale health systems improvement project in an uncontrolled setting: a quality improvement initiative in KwaZulu-Natal, South Africa. BMJ Qual Saf 2012. [PMID: 23204513 DOI: 10.1136/bmjqs-2012-001244] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE New approaches are needed to evaluate quality improvement (QI) within large-scale public health efforts. This case report details challenges to large-scale QI evaluation, and proposes solutions relying on adaptive study design. STUDY DESIGN We used two sequential evaluative methods to study a QI effort to improve delivery of HIV preventive care in public health facilities in three districts in KwaZulu-Natal, South Africa, over a 3-year period. We initially used a cluster randomised controlled trial (RCT) design. PRINCIPAL FINDINGS During the RCT study period, tensions arose between intervention implementation and evaluation design due to loss of integrity of the randomisation unit over time, pressure to implement changes across the randomisation unit boundaries, and use of administrative rather than functional structures for the randomisation. In response to this loss of design integrity, we switched to a more flexible intervention design and a mixed-methods quasiexperimental evaluation relying on both a qualitative analysis and an interrupted time series quantitative analysis. CONCLUSIONS Cluster RCT designs may not be optimal for evaluating complex interventions to improve implementation in uncontrolled 'real world' settings. More flexible, context-sensitive evaluation designs offer a better balance of the need to adjust the intervention during the evaluation to meet implementation challenges while providing the data required to evaluate effectiveness. Our case study involved HIV care in a resource-limited setting, but these issues likely apply to complex improvement interventions in other settings.
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Affiliation(s)
- Kedar S Mate
- Institute for Healthcare Improvement, , Cambridge, Massachusetts USA
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